Healthcare Provider Details

I. General information

NPI: 1033904354
Provider Name (Legal Business Name): IDHIKA JOLLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2025
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 E BRIER DR STE 200
SAN BERNARDINO CA
92408-2847
US

IV. Provider business mailing address

658 E BRIER DR STE 200
SAN BERNARDINO CA
92408-2847
US

V. Phone/Fax

Practice location:
  • Phone: 909-501-0700
  • Fax: 909-387-7611
Mailing address:
  • Phone: 909-501-0700
  • Fax: 909-387-7611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: